Second-look laparotomy in epithelial ovarian cancer.

The absence of a reliable noninvasive means of detecting persistent clinically occult ovarian cancer is the basis for performing repetitive operative procedures, usually called a second-look. Although controversy persists regarding whether second-look surgery contributes to an improved survival, it is well established that the second-look findings are of prognostic value. Patients with no pathologic evidence of tumor at second-look surgery (negative second-look) are much more likely to experience a prolonged disease-free interval than are patients with evidence of gross tumors at second-look (macroscopic positive second-look). Likewise, patients without gross tumor but with pathologic or cytologic disease (microscopic positive second-look) tend to survive longer than patients with a macroscopic positive second-look, but they do more poorly than patients with a negative second-look. It is also well known, however, that there are other prognostic features that influence clinical outcomes. For example, patients who have a negative second-look after treatment for a stage IIIC, grade 3 epithelial ovarian carcinoma should be considered at higher risk (50%) for an earlier clinical relapse than patients with low-grade tumors (grade 1 or low malignant potential) who have microscopic or small-volume gross tumors at second-look surgery. Much attention has been directed to whether second-look surgery has a favorable impact on survival. Unfortunately, no blind randomized trials have addressed this question. The conduct of a trial to evaluate the impact of second-look surgery on survival would be most difficult and essentially impossible because of an inability to standardize or control the treatment for recurrent tumors. Even measuring the interval of progression-free disease from completion of primary chemotherapy would be a challenging clinical trial to execute.